What happens to your body during menopause

Ask four midlife women about menopause and you’ll get four completely different answers. Every woman’s menopause is different, from the level of intensity they experience (one in four women suffer to an extreme degree) to their range of symptoms. Hot flushes and anxiety are the most commonly known, but there are more than 30 and counting. 

According to a 2022 survey of 947 perimenopausal British women over the age of 40, more than half did not feel informed about the menopause. This shouldn’t come as a surprise. According to data from Menopause Support, more than 60 per cent of women feel they do not have a GP at their local practice who can advise them on menopause. The reason is simple: not enough GPs are trained in menopause care. In 2021 only 59 per cent of UK medical schools had menopause as a mandatory subject, although this is finally changing. 

Other than hot flushes, most of the participants in the 2022 study above were unaware of the wide array of symptoms that occur to women at this life stage and so did not connect them to perimenopause. This despite the fact that women in the group reported symptoms as various as mood swings (68.9 per cent), brain fog (68.3 per cent) and fatigue (66.8 per cent), with 79.1 per cent also reporting symptoms affecting their desire for sex. 

According to the Fawcett Society, one in 10 menopausal women leave their jobs because of their symptoms. For women, getting information early on and ensuring they know who to turn to when symptoms first appear is critical. 

What is the menopause? 

Menopause is a term that refers to the transition women experience towards the end of their childbearing years as the number of eggs in their ovaries decreases, they stop having periods and the production of the hormones oestrogen and progesterone begins to slow down. There are three phases to this transition, which on average occurs between the ages of 45 and 55. While almost every woman will go through all three phases of menopause, each one experiences it differently. 

The three stages of menopause 

Perimenopause is defined as the period of time when a woman’s body is moving toward menopause. Periods may become irregular, fertility is reduced and the production of hormones begins to fluctuate and slow down. The average age women experience perimenopause in the UK is 45, although some experience symptoms earlier. This phase can last from 12 months to five years or more. 

Menopause is the point when a woman has not had a period for a year and is confirmation that the body has stopped producing the hormones that cause menstruation. The average age of menopause in the UK is 51, although this varies from woman to woman. 

Postmenopause begins after the menopause has happened and lasts for the remainder of a woman’s life. Menopausal symptoms are similar to perimenopausal symptoms and can continue for five to seven years after menopause – some even longer. For example, according to online menopause clinic My Menopause Centre, 40 per cent of women aged between 60 and 65 will experience hot flushes and night sweats. 

Signs that you’re perimenopausal 

“Perimenopause splits into two phases,” explains menopause specialist Dr Shahzadi Harper. “At first the changes can be quite delicate. They can start to occur in your early-40s, and there are physical symptoms and psychological ones,” she says. “Your menstrual cycle might shorten from 28 days to 26 days, your periods might be heavier and you might not be sleeping so well. You may also be starting to feel overwhelmed and anxious, while experiencing a loss of joy, a loss of libido, or a feeling that you can’t be bothered.” 

The second phase, which can run from a woman’s mid-40s to early-50s, includes vaginal and vulval dryness, may cause painful intercourse, night sweats, brain fog and indecisiveness, according to Harper, and she notes, “Weight gain becomes harder to lose.” 

Symptoms of menopause 

“The main symptoms of menopause fall into four key areas,” says Dr Clare Spencer, registered menopause specialist, GP and co-founder of My Menopause Centre. “Firstly there are vasomotor symptoms, which include hot flushes and night sweats. 

Physical symptoms include muscle and joint aches, as well as headaches, palpitations, poor sleep, a sensation of burning in the mouth, and skin dryness and itching, known as formication. Finally in the physical category, there are bladder symptoms, which include increased frequency, passing urine in the night and discomfort and pain when passing urine,” says Spencer, adding, “Symptoms can mimic a urinary tract infection – and it is important to rule this out. 

“Psychological symptoms, which can be the most distressing for many women, include anxiety and depressive symptoms on a spectrum of severity. And lastly, cognitive symptoms include poor memory, brain fog and trouble finding words.” 

Lesser-known symptoms 

“We now know that oestrogen is important for the whole body, which means it can affect everything,” says Harper. Unexpected symptoms may include frozen shoulder, tinnitus, dental symptoms connected to bone density, such as gum inflammation and sensitivity (including a condition known as menopausal gingivostomatitis) and loose teeth, dry mouth and dry eyes. 

How menopause affects your body 

Your bones and muscles 

With age, our bones become fragile and break more easily, largely the result of a decline in oestrogen. Osteoporosis, the loss of density in bones, has no symptoms – until a bone breaks. 

“Bone loss accelerates through the menopause as a direct effect of loss of oestrogen”, says Spencer. “One in three women will be impacted by osteoporosis, so it is important to tackle it early. That means taking vitamin D and ensuring the level of calcium in your diet is adequate. The Royal Osteoporosis Society has a risk calculator that can help you identify whether you need to take a supplement to boost your calcium intake.” 

In a study of midlife women published in 2020, researchers found that doing exercise to build muscle mass was associated with a lower risk of sarcopenia, the age-related loss of skeletal muscle, in older women. 

“For women it is fundamental to understand muscle and the importance of building it,” stresses Kate Rowe-Ham, midlife fitness expert and author of Owning Your Menopause: Fitter, Calmer, Stronger in 30 Days. “Muscle is important for hormonal balance, and research shows that strength training can affect hormonal regulation. Building muscle reduces symptoms and protects the metabolism.” 

Muscle also helps with bone health. As oestrogen continues to decline during perimenopause and menopause, osteoporosis becomes a risk. “Maintaining muscle improves bone density because the stronger the muscles, the more force they will have on your bones,” she says.

Effects of menopause on skin 

Like so much else in the midlife woman’s body, skin is impacted by menopausal changes in hormone production. “With the loss of oestrogen, the body produces less sebum and the skin becomes dry,” explains Spencer. “There is also an increase in wrinkling as collagen and elastin production slows down. This impairs wound healing, weakening the barrier function, and there is a reduction in skin turgor, the level of elasticity in our skin,” she adds. 

Some of these changes are due to the natural ageing process or the impact of smoking, sun damage or alcohol. “The best thing you can do is take control of the controllable factors that make this worse,” Spencer advises. “Reduce your alcohol intake, reduce stress, do more exercise and wear sunblock.” 

Dr Emma Wedgeworth, consultant dermatologist and spokesperson for the British Skin Foundation, comments, “I see a marked increase in skin sensitivity [at menopause]. The decline in oestrogen levels impacts on the skin barrier, as well as causing a reduction in glycosaminoglycans, the natural water-holding molecules of the skin. This can result in flaking, redness and burning of the skin.” 

Flaking and redness is also a sign of rosacea, a chronic inflammatory skin condition that makes the skin red or rosy and is often triggered by stress, diet, sun exposure or hot flushes – it tends to get worse during menopause. Acne too is increasingly becoming a midlife issue, with between 20 and 40 per cent of menopausal women experiencing symptoms, according to a report published in the International Journal of Women’s Health. 

This is due, again, to the balance of women’s hormones changing as androgen, a hormone produced by men and women, becomes relatively more present in the body. Lifestyle issues such as poor diet, sleep deprivation and stress are also factors. Topical solutions can be prescribed, but oral contraceptives, sometimes used to deal with these symptoms, are obviously not relevant for postmenopausal women. 

“For intense dryness, we need richer skincare and to add more lipids and natural fats back into the skin,” explains skin health specialist Annee de Mamiel. “Lipids are essential components of our skin and play a crucial role in maintaining the strength of the skin’s protective barrier. They also aid the skin’s natural repair process. Ceramides, a type of lipid that is proven to increase the skin’s hydration and barrier function, are especially important. Ceramide deficiency, which also occurs as we age, is the main cause of dry skin, so ceramides in skincare products can be replenishing.” De Mamiel stresses the importance of SPF to protect from sun damage and skin pigmentation. 

Effects of menopause on hair 

Hair loss is experienced by 40 per cent of postmenopausal women, according to consultant dermatologist Dr Sajjad Rajpar writing in Balance from Newson Health, with some women experiencing hair loss earlier, during the perimenopause. Problems can range from smaller hair diameter, changes in texture and a more delicate hair shaft that can’t handle heat or chemicals well to female pattern hair loss (FPHL) and thinning across the head. While hormonal changes are responsible for much of this, stress can also be a factor. 

Hair loss can have a huge impact on self-esteem and quality of life. The issue is predominantly due to the decline in oestrogen and progesterone, which protect hair growth, and the relative increase of androgen, a hormone produced by men and women that is related to baldness. “There are limited options in terms of what doctors can do for hair loss, and there is no evidence that HRT helps,” says Spencer. “Low iron can be related to hair loss, and an underactive thyroid can impact it as well.” 

For women with FPHL, hair-loss treatment minoxidil, which can be bought without prescription in the UK, may be the best option, while a consultation with a dermatologist who specialises in menopausal hair loss is worth considering. For those with less serious symptoms, washing your hair every day is recommended to cleanse the hair follicles, as well as applying moisturising conditioners and masks to coat the hair shaft and maintain a healthy scalp, and avoiding hair dryers and curling irons that can dry hair out and burn the scalp. 

Menopause and your weight 

“Perimenopausal women will often say their body thickened overnight,” says nutritionist Emma Bardwell. “They feel their weight is out of control and that all the measures they previously put in place to lose a few pounds no longer work.” 

As oestrogen levels decline, women tend to put weight on around the abdomen. About 50 per cent of women gain weight during perimenopause at an average 1.5kg a year, according to the British Menopause Society. But experts are clear that weight gain is also connected to the genes we inherit from our parents and lifestyle issues. 

“Trying to lose weight by focusing on food is like trying to quit drinking by focusing on alcohol,” says Bardwell. “In the clinic, the best results occur when women look at their eating habits and behaviours, rather than purely focusing on calories. Your genetics play a part and so does your environment, your job, your family and your socio-economic background.” 

“Nutrition doesn’t have to be expensive or complicated. Eat according to your daily energy needs, make sure you’re getting plenty of plants for fibre, protein for muscle and calcium for bone health,” Bardwell continues. “You don’t need masses of supplements but it is worth taking vitamin D3, which helps regulate calcium and phosphate levels and is important for bone health, immunity and mood. Omega-3 is important primarily for brain health and inflammation, which can rise at menopause, while magnesium is good for anxiety, restless legs and sleep. Some recent studies have linked the potential benefits of creatine to cognition and brain fog, as well as muscle strength and stamina.” 

Fitness also has an important role to play here, and Kate Rowe-Ham urges women to focus on exercise that builds muscle, such as strength training. “If women are so focused on losing weight and exercising, they may miss the point that training for muscle strength will burn more fat. Even resting muscle burns more calories than fat.” 

Menopause and mental health 

Mental health for women at midlife is an intricate combination of physical symptoms, emotional issues and the reality of ageing. Women’s stories of leaving the keys in the fridge, being so anxious they forget how to drive, and anger so strong they throw something in rage are much more frequent than we might think. 

“When women experience perimenopause and their oestrogen levels go down, it affects the amygdala [a part of the brain associated with emotional processes],” explains Lina Mookerjee, a BACP senior accredited integrative counsellor and psychotherapist. “Women are good at tolerating distress because oestrogen buffers the emotions. When there is no more regulation of the amygdala by oestrogen, the lid comes off.

“There is no way for women to express their anger: we avoid conflict and don’t understand how to manage it because we have been conditioned to be nice,” says Mookerjee. “Many issues are finally recognised at midlife: trauma, lack of care or neglect – whatever it is that has happened – all the way back to childhood. Therapy helps women begin to process and regulate distress. It offers a safe space for this exploration.” 

“Psychologically perimenopause and menopause are quite a struggle for all kinds of reasons,” says Louise Chunn, mental health expert and founder of Welldoing.org, a matching service for therapists and clients across the UK. “Traditionally, this is where the bump comes in therapy. The end of fertility for some people is really impactful, or when the kids leave the house and caring duties rear their head. It’s the sandwich generation who have to handle everything,” she says. 

Draft guidance from Nice has recently promoted CBT as a suitable therapy for depressive symptoms during the menopause. There is evidence that this form of therapy can also help make night sweats less severe and frequent and could be considered alongside or as an alternative to HRT. “Sometimes talking to someone like a therapist around the time of the menopause helps you accept that change doesn’t have to mean diminution, it is just change,” says Chunn.

“HRT can help manage the mild to moderate end of the spectrum of these symptoms,” says Spencer. “I sometimes say that HRT smooths the jagged edges of anxiety. It can take some of the symptoms away, and for many that will be all they need. More severe anxiety that is impacting a woman’s quality of life may need a different solution. It is important to remember that HRT is not a magic bullet, and that there will still be some ups and downs.” 

“Exercise is a fantastic mood booster and can empower women to feel more confident at a time when self-doubt can escalate,“ says Rowe-Ham. “Most women have the ability to move regardless of their HRT status and it is without doubt one of the most effective tools they can use.”

Menopause and sexual health 

For a woman, feeling secure both in her sexuality and sexual health can be an emotional business at midlife. “Because our bodies are changing, we lose confidence,” explains relationship and psychosexual therapist Selena Doggett-Jones. “A lot of women gain weight, and your libido is very much based on how you feel about yourself.” 

If sex was a big part of your self-esteem, and your libido and sense of desire slows at perimenopause, it can be shattering. “You can’t address sexual health without looking at the relationship you are in, if you are in one,” says Doggett-Jones. “Your ability to want to be intimate with a person depends on how you are being accepted.” 

Tracey Cox, sex educator and author of Great Sex Starts at 50, says that part of the frustration for midlife women is that sexual desire is no longer spontaneous, but reactive, meaning that women take a little longer to reach arousal. 

From a physical point of view, not only are our bodies ageing, but as oestrogen production slows, vaginal dryness occurs. One of the key contributors to painful intercourse, vaginal dryness affects 45 per cent of women in late perimenopause and postmenopause, according to Swan, a longitudinal study on women’s health and the menopause transition. Healthy sexual function is most impacted in the 20 months leading up to a woman’s final period and a year after as hormone production slows down.

Luckily, there is a lot that can be done to address these issues. You can manage vaginal symptoms with vaginal oestrogen or non-hormonal moisturisers and lubricants that are designed for the vagina. “Vaginal oestrogen addresses vaginal and vulval dryness, irritation, soreness, drying skin, delicate skin, tears and bleeds,” says Spencer. “Reduced libido can occur as a result of loss of testosterone,” she adds, “so replacing a small amount by using a testosterone cream or gel can be helpful in heightening arousal.” 

And a word of warning: “If a woman bleeds after menopause, she needs to get medical help immediately, says Doggett-Jones. “Whether it is bleeding after sex or bleeding after a long gap in time, it needs to be checked. It could be vaginal atrophy, chlamydia or something more serious.” 

Long-term risks associated with menopause 

“Women’s health risks for chronic disease increase quite significantly over menopause due to the decline of oestrogen and testosterone,” says Dr Shahzadi Harper. This can include osteoporosis, an increased risk of heart disease, diabetes, urinary tract infections, depression, obesity and dementia, where more research is currently being done. 

While the British Menopause Society recommends a lower dosage of HRT for women over 60 who wish to continue on it long-term, Spencer explains: “HRT should be taken primarily to manage symptoms of the menopause. It can also help prevent osteoporosis and osteoporotic fracture and, if started early in the menopause transition, may help prevent heart disease. It is likely that the dose of oestrogen needed to manage symptoms decreases with age.” 

Diet and exercise are fundamental tools that can help every woman protect herself from serious health outcomes. “Your body simply isn’t the same as it was when you were 20 or 30”, points out nutritionist Emma Bardwell. “You need to be really focusing on your heart, brain and bones at this time. Nutrition plays a pivotal role in futureproofing peri- and postmenopausal women’s health.” 

“Exercise helps to manage a myriad of symptoms,” points out fitness expert Kate Rowe-Ham. “It’s great to have in your toolkit, and research shows that it does reduce menopause symptoms. It helps with hormone regulation and has an impact on anxiety and depression because it builds up endorphins and serotonin. Strength training and weight-bearing exercise is especially important in maintaining muscle mass and overall strength as we age,” she continues. “Muscle mass is associated with longevity and may reduce your risk of cardiovascular disease, diabetes, osteoporosis, and early death.” 

How I got through menopause 

Lise Thorne, 47, IT business owner 

“I was 39 and my hormones were changing, but I had no idea why I was feeling unsatisfied. Physically I didn’t feel the same but I didn’t know it was perimenopause. 

“That’s when I found exercise. I went on a Thai boxing retreat in Phuket, and then I moved onto triathlons. My first triathlon was held at Hever Castle and I was so nervous, but I met another woman the same age as me in the race and we did it together. It felt amazing. That’s where my passion for coldwater swimming started. It’s the combination of things that I love: nature, the cold water and the space. 

“I couldn’t swim four strokes of front crawl when I started with my trainer [15 years ago]. This year I did the Dart10k, a marathon-distance swim on the River Dart. My body is not as fast or supple as it was, but as long as you can make it to the start, you just keep swimming. 

“Now I train in a pool on a Sunday evening with a club, and I feel amazing once I’ve done it. The swimming club is a great equaliser – all shapes and sizes are welcome. Menopause to me is a double whammy of heightened anxiety and creaking bodies. When I was younger I thought about ageing in terms of grey hair and wrinkles, but I didn’t think about fading energy levels and ageing bodies – which I didn’t like! But exercise has changed that for me. Now I want to do an Iron Swim before I turn 50.”

Tracy Booth, 52, part-time learning support assistant 

“Looking back, I was probably about 46 when I started perimenopause. When my mum had her menopause I had already left home so I didn’t see what she went through, but my kids have felt the effects of what is going on in my life. I was short-tempered and my kids had to be more tentative around me. 

“Then I had a few ‘turns’. I lost my balance walking across the school hall in 2019. The specialist thought it might be part of the menopause, alongside the migraines I suffered. After my 50th birthday I went on HRT and it has been fantastic. It dealt with my migraines, the itching on the palms of my hands and the temper tantrums. 

“At menopause I wasn’t sure what the missing piece of the puzzle was for me. In fact it was about finding something for me and not for anyone else. Then, in September 2021, I joined a choir called Pop Chorus. We sing in a village hall which has a vaulted ceiling and it is incredible. I love it because it’s inclusive of everybody. It isn’t just old ladies who have nothing to do. This is exercising my mind and helping with my breathing. I had some palpitations coming into menopause and this has helped. When you are taught to breathe by a vocal coach, you breathe! 

“For me, choir is really grounding. You aren’t thinking about anything else, just the singing. It calms me down, which is really important for me at menopause. It’s kind of a reset and allows me to refocus and find life’s balance.” 

Juliet Warkentin is co-founder of Hylda, a beauty and wellness platform for midlife women.